Randomized intubation with polyurethane or conical cuffs to prevent pneumonia in ventilated patients.

RATIONALE: The occurrence of ventilator-associated pneumonia (VAP) is linked to the aspiration of contaminated pharyngeal secretions around the endotracheal tube. Tubes with cuffs made of polyurethane rather than polyvinyl chloride or with a conical rather than a cylindrical shape increase tracheal sealing. OBJECTIVES: To test whether using polyurethane and/or conical cuffs reduces tracheal colonization and VAP in patients with acute respiratory failure. METHODS: We conducted a multicenter, prospective, open-label, randomized study in four parallel groups in four intensive care units between 2010 and 2012. A cohort of 621 patients with expected ventilation longer than 2 days was included at intubation with a cuff composed of cylindrical polyvinyl chloride (n = 148), cylindrical polyurethane (n = 143), conical polyvinyl chloride (n = 150), or conical polyurethane (n = 162). We used Kaplan-Meier estimates and log-rank tests to compare times to events. MEASUREMENTS AND MAIN RESULTS: After excluding 17 patients who secondarily refused participation or had met an exclusion criterion, 604 were included in the intention-to-treat analysis. Cumulative tracheal colonization greater than 10(3) cfu/ml at Day 2 was as follows (median [interquartile range]): cylindrical polyvinyl chloride, 0.66 (0.58-0.74); cylindrical polyurethane, 0.61 (0.53-0.70); conical polyvinyl chloride, 0.67 (0.60-0.76); and conical polyurethane, 0.62 (0.55-0.70) (P = 0.55). VAP developed in 77 patients (14.4%), and postextubational stridor developed in 28 patients (6.4%) (P = 0.20 and 0.28 between groups, respectively). CONCLUSIONS: Among patients requiring mechanical ventilation, polyurethane and/or conically shaped cuffs were not superior to conventional cuffs in preventing tracheal colonization and VAP. Clinical trial registered with clinicaltrials.gov (NCT01114022).

Polymorphisms in the Pseudomonas aeruginosa type III secretion protein, PcrV - implications for anti-PcrV immunotherapy.

The type III secretion system of Pseudomonas aeruginosa, responsible for acute infection, is composed of over twenty proteins that facilitate cytotoxin injection directly into host cells. Integral to this process is production and secretion of PcrV. Administration of a recently developed, anti-PcrV immunoglobulin, either as a therapeutic or prophylactic has previously demonstrated efficacy against laboratory strains of P. aeruginosa in a murine model. To determine if this therapy is universally applicable to a variety of P. aeruginosa clinical isolates, genetic heterogeneity of pcrV was analyzed among strains collected from three geographically distinct regions; United States, France and Japan. Sequence analysis of PcrV demonstrated limited variation among the clinical isolates examined. Strains were grouped according to the presence of non-synonymous single nucleotide polymorphisms. Representative isolates from each mutant group were examined for the ability of anti-PcrV to bind the protein secreted by these strains. The protective effect of anti-PcrV IgG against each strain was determined using an epithelial cell line cytotoxicity assay. The majority of strains tested demonstrated reduced cytotoxicity in the presence of anti-PcrV IgG. This study provides insights into the natural sequence variability of PcrV and an initial indication of the amino acid residues that appear to be conserved across strains. It also demonstrates the protective effect of anti-PcrV immunotherapy against a multitude of P. aeruginosa strains from diverse global regions with a variety of mutations in PcrV.

Diagnostic accuracy of a rapid real-time polymerase chain reaction assay for universal intrapartum group B streptococcus screening.

BACKGROUND: Intrapartum antibiotic prophylaxis is currently given to mothers who test positive for group B streptococcus (GBS) by antenatal culture-based screening, with a risk-based approach for cases with an unknown GBS status. A rapid real-time polymerase chain reaction (PCR) assay for the detection of GBS became available recently, making intrapartum screening possible. We aimed to assess its diagnostic accuracy and to compare it with antenatal screening. METHODS: We conducted a prospective study in a French hospital. All pregnant women giving birth at the maternity ward were considered for inclusion, except those with planned cesarean delivery, with delivery at <35 weeks gestation, and who received antibiotic therapy before admission. We performed GBS culture (the reference standard) and a molecular GBS test (Xpert GBS; Cepheid) on intrapartum specimens. Decisions about intrapartum antibiotic prophylaxis were based on the current GBS screening by culture at 35-37 weeks gestation. RESULTS: We prospectively enrolled 968 pregnant women from April 2007 through March 2008. The overall molecular GBS test yield was 89.2%. Among the 863 women with available results, the molecular GBS test had a sensitivity of 98.5%, specificity of 99.6%, positive predictive value of 97.8%, and negative predictive value of 99.7%. The positive predictive value of antenatal culture for identifying colonization status at delivery was low (58.3%), whereas the negative predictive value was imperfect (92.1%). CONCLUSIONS: This real-time PCR assay is a highly accurate test to identify intrapartum GBS carriers at point of care. This new tool could enhance the exact identification of candidates for intrapartum antibiotic prophylaxis, including women with preterm rupture of membranes or preterm labor.

Optimization of the ß LACTA test for the detection of extended-spectrum-ß-lactamase-producing bacteria directly in urine samples.

The ß LACTA™ test (BLT) is a chromogenic test detecting resistance to third-generation cephalosporins on bacterial colonies. Some studies have shown that this test can be used directly in urine samples. The aim of this study was to determine the optimal conditions of use of this test in order to detect the ESBL-producing bacteria directly in urine samples. During a 4-months period, a total of 365 consecutive urine samples were tested with the BLT using the recommendation of the manufacturer. We isolated 56 ESBL-producing bacteria and 17 AmpC-overproducing bacteria. ESBL- and/or AmpC ß-lactamase-producing bacteria isolates were systematically characterized by disc diffusion antibiotic susceptibility testing interpreted according to the guidelines of EUCAST. The sensitivity and the specificity for 3GC-resistance detection, regardless the mechanism of resistance, were, respectively, 60.3% and 100%, whereas for ESBL detection, it was, respectively, 75.4% and 99.7%. We applied then modification of the initial protocol considering urines with a bacteriuria >1000/µL, a reading time at 30 min and considering any change of the initial colour as positive. The overall sensitivity was 81% and the sensitivity for ESBL-detection raised to 95.7%.

Ten-year decrease of acquired methicillin-resistant Staphylococcus aureus (MRSA) bacteremia at a single institution: the result of a multifaceted program combining cross-transmission prevention and antimicrobial stewardship.

BACKGROUND: In France, the proportion of MRSA has been over 25% since 2000. Prevention of hospital-acquired (HA) MRSA spread is based on isolation precautions and antibiotic stewardship. At our institution, before 2000, the Infection Disease and the Infection Control teams had failed to reduce HA-MRSA rates. OBJECTIVES AND METHODS: We implemented a multifaceted hospital-wide prevention program and measured the effects on HA-MRSA colonization and bacteremia rates between 2000 and 2009. From 2000 to 2003, active screening and decontamination of ICU patients, hospital wide alcohol based hand rubs (ABHR) use, control of specific classes of antibiotics, compliance audits, and feed-backs to the care providers were successively implemented. The efficacy of the program was assessed by HA-MRSA colonized and bacteremic patient rates per 1000 patient-days in patients hospitalized for more than twenty-four hours. RESULTS: Compliance with the isolation practices increased between 2000 and 2009. Consumption of ABHR increased from 6.8 L to 27.5 L per 1000 patient-days. The use of antibiotic Defined Daily Doses (DDD) per 1000 patient-days decreased by 31%. HA-MRSA colonization decreased by 84% from 1.09 to 0.17 per 1000 patient-days and HA-MRSA bacteremia by 93%, from 0.15 to 0.01 per 1000 patient-days (p < 10-7 for each rate). CONCLUSIONS: In an area highly endemic for MRSA, a multifaceted prevention program allows for sustainable reduction in HA-MRSA bacteremia rates.